Global health training is increasing in prominence in U.S. premedical education1 and both undergraduate2 and graduate3,4 medical education. The availability of global health training opportunities has been shown to affect medical students' selections in the U.S. National Resident Matching Program5–8 and their subsequent decisions to seek employment in underserved communities or pursue graduate education in public health.9,10 Although residency programs have, in general, responded to this increased demand by expanding global health training opportunities for residents as a whole,11 the extent to which such expansions have occurred specifically in the field of obstetrics and gynecology is unclear.
Global health training in obstetrics and gynecology residency programs is of substantive public health concern, because maternal conditions are a leading cause of death among women of reproductive age worldwide.12 Moreover, cesarean deliveries are among the most common surgical procedures performed in low-resource settings,13,14 and the rates of obstetric complications in low-resource countries exceed those in other parts of the world.15 A major bottleneck to improving surgical care in general is the lack of adequately trained health care providers.16–18 Overall, in many low-resource countries, access to essential obstetric and gynecologic services remains limited.19
In July 2012, the Executive Board of the American College of Obstetricians and Gynecologists issued a Statement of Policy supporting women's health and rights globally. However, to date, the literature has only contained case studies of global health training programs for obstetrics and gynecology residents at specific institutions (eg, the Global Health Residency Track in the Department of Obstetrics, Gynecology, and Reproductive Sciences at Mount Sinai School of Medicine20). The magnitude and distribution of global health training in obstetrics and gynecology have not been systematically assessed. We undertook this study to quantify the extent of global health training in U.S. obstetrics and gynecology residency programs. A secondary aim was to compare, at the country level, the distribution of programmatic activity with the maternal and perinatal disease burden.
We implemented a standardized search protocol to systematically identify and characterize global health-related programmatic activities in U.S. obstetrics and gynecology residency programs. First, we identified all U.S. obstetrics and gynecology residency programs (numeric program code 220) accredited by the Accreditation Council for Graduate Medical Education for the academic year 2010–2011. Using this nationwide sampling frame, one of the study authors (V.B.K.) and two research assistants examined the official residency program web site, if available, and search results from systematic Google queries. We chose to use a web-based search instead of direct surveys of program directors or residents, because anonymous surveys of global health training activities have often yielded little response from prospective participants (either program directors or residents), and previously published journal articles have been based on data from surveys with response rates as low as 25%.8,21–23 The Google queries were conducted January–June 2011 and, using the “Find pages with all these words” function, searched for the following: [Accreditation Council for Graduate Medical Education-listed program name] global health obstetrics gynecology residency. The first page of 20 search results as well as any linked web pages with the keywords “enrichment,” “global health,” “health inequity,” “international health,” “research,” “rural,” or “vulnerable populations” were scanned for relevant data. Data linking the Accreditation Council for Graduate Medical Education-accredited residency program to global or international health-related programmatic activities were abstracted from any of these web pages. A program was coded as not having any global health training if neither the official residency program web site nor the Google queries uncovered any relevant data.
We categorized global health programs into four nonmutually exclusive categories of programmatic activity. “Electives” were defined as clinical or educational activities of less than 6 weeks' duration. Engagements lasting 6 weeks or more, with or without designated didactic study in global health, were categorized as “extended field training.” Any activities involving human subjects research (ie, interaction with living persons, the use of identifiable private information, or both) were categorized as “research” regardless of duration. If a particular global health-related programmatic activity did not fit one of these three categories or could not be characterized (eg, as a result of lack of information), it was listed as “other.” We summated the total count of programmatic activities across residency programs and across countries. Selected programs with longitudinal curricula and established ties to partner institutions were then described in more detail.
This study did not involve human subjects research and received an exempt determination from the Partners Human Research Committee.
We sought to estimate the cross-country association between programmatic activity and disease burden. To measure disease burden, we abstracted data on disability-adjusted life-years as a result of maternal and perinatal conditions and gynecologic cancers for each country with any programmatic activity from the Global Burden of Disease study.24 For this analysis we adopted the same general categorizations used in the Global Burden of Disease study: “maternal conditions” included maternal hemorrhage, maternal sepsis, hypertensive disorders of pregnancy, obstructed labor, and abortion; “perinatal conditions” included prematurity and low birth weight, birth asphyxia and birth trauma, and neonatal infections and other conditions; and “gynecologic cancers” included cervical, uterine, and ovarian cancer. We calculated Spearman's rank correlation coefficients and their 95% confidence intervals to estimate the association between programmatic activity and disease burden. Scatterplots were used to display this information graphically. For graphical visualization, to determine whether the best fit to the line was linear, quadratic, or cubic, we fitted ordinary least squares regression models to the data using Huber-White standard errors to ensure that the estimates were robust to distributional assumptions. The dependent variable was specified as the number of programs and the explanatory variable specified as the burden of disease per 100,000 disability-adjusted life-years. We sequentially added quadratic or cubic terms to the regression models, assessed their incremental contributions to the models using Wald-type F-tests, and selected a quadratic or cubic fit line based on these findings. All statistical analyses were conducted using the Stata/MP 12.0 software package.
From among the 243 Accreditation Council for Graduate Medical Education-accredited obstetrics and gynecology residency programs in the United States, we identified 41 (17%) residency programs that provided details of their global health training opportunities online. These programs offered a total of 69 global health-related programmatic activities. Electives were by far the most prevalent type of programmatic activity, offered by 33 programs. Another 18 residency programs offered research opportunities, whereas only eight offered extended field-based training. Ten residency programs offered global health-related programmatic activities that did not fall into one of the three categories or could not otherwise be classified. Selected programs' global health activities are described in more detail in Table 1.
There were a total of 128 sites of programmatic activity dispersed across 64 different countries, indicating that residency programs typically offered a given activity at multiple sites. The density of programmatic activity had a statistically significant association with the country-level burden of disease as a result of maternal conditions (Spearman's ρ=0.37, 95% confidence interval [CI] 0.14–0.57) (Fig. 1) and perinatal conditions (ρ=0.34, 95% CI 0.10–0.54). The regression analyses suggested a quadratic fit modeled the data best with the intensity of programmatic activity increasing with disease burden at the lower end of the scale and then decreasing with disease burden at the upper end of the scale. The cross-country association between programmatic activity and gynecologic cancers was negative but not statistically significant (ρ=−0.24, 95% CI −0.46 to 0.01). When we examined the correlations for the different types of gynecologic cancers separately, we observed a negative and statistically significant association between programmatic activity and uterine (ρ=−0.48, 95% CI −0.65 to −0.27) and ovarian (ρ=−0.26, 95% CI −0.48 to −0.01) cancers but a null association with cervical cancers (ρ=−0.02, 95% CI −0.27 to 0.23).
In this systematic enumeration of global health training across all U.S. obstetrics and gynecology residency programs, we identified only 41 residency programs that described their global health-related training opportunities online. The cross-country associations between the intensity of programmatic activity and maternal and perinatal disease burden were statistically significant but relatively small in magnitude, suggesting that training opportunities appear to be distributed according to the global burden of maternal and perinatal conditions. Our findings have substantive implications for U.S. graduate obstetrics and gynecology education both in terms of quantifying the relatively low rates of global health training and identifying the potential for improved programming in the future.
Relative to the fields of internal medicine25 and pediatrics,8,21 we found fewer U.S. obstetrics and gynecology residency programs with global health training opportunities. The Residency Review Committee for Obstetrics and Gynecology currently permits international experiences to count toward graduation and does not specifically exclude cases obtained during these experiences from counting toward Accreditation Council for Graduate Medical Education requirements. Given these favorable allowances in obstetrics and gynecology, the greater prevalence of global health training opportunities in other fields may be the result of the intensive service requirements of obstetrics and gynecology residency programs, which are also smaller in class size compared with other specialties. Call-free time is rare. For example, unless a resident has elective time dedicated for an overseas elective in which she or he is not a member of the overnight call pool, any clinical duties missed must be covered by other residents in the program. Similar considerations have been described as hampering the expansion of global health training opportunities in U.S. graduate surgical education22,26 despite active resident interest.27,28
Among the programs we identified as having established relationships with international partner institutions, none provided funding for trainees from partner institutions to access learning opportunities in the United States This disparity is consistent with the review of general surgery global health residency programs by Jayaraman et al,22 in which few programs offered faculty or residents from partner institutions to travel to the United States. These asymmetries are likely driven not only by funding constraints (eg, the extent to which U.S. institutions are willing or able to provide funding for trainees from partner institutions to access learning opportunities in the United States), but also by regulatory constraints (eg, licensure requirements that limit the extent to which foreign medical graduates are permitted to engage in clinical work in the United States). Different programs have adopted different models to address these issues. The Michigan State University Program hosts residents from its partner sites in Costa Rica, but all costs are borne solely by participating residents—suggesting important limitations in the extent to which a similar model could be implemented with partner institutions in sub-Saharan African countries where the per-capita gross domestic product is typically lower by an order of magnitude. The University of Toronto Department of Obstetrics and Gynecology—excluded from this review, along with other residency programs not based in the United States—hosts trainees from Moi University, Kenya, as part of the Academic Model Providing Access to Healthcare consortium led by Indiana University. Moving forward, we believe the continued gaps in the learning experiences of trainees from the United States compared with those from partner institutions should be addressed in the development of new obstetrics and gynecology global health residency programs.
The relative lack of global health training among U.S. obstetrics and gynecology residency programs that we identified in our study suggests lost opportunities from multiple vantage points.27,29 U.S. residents lose critical opportunities to increase their mastery of Accreditation Council for Graduate Medical Education core competencies in a different setting. The disparities in resources across various global settings offer U.S. residents the opportunity to broaden and deepen their mastery of core competencies (patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice) in their graduate surgical education, as has been described first-hand.30 Because the variety and volume of diseases vary worldwide, so does the availability of technology and thus the need for residents trained in highly technology-driven settings to rely on their basic clinical and leadership skills to obtain information and communicate effectively. The perspectives of other stakeholders are relevant as well. Faculty members lose opportunities to engage in collaborative research, sharing of educational resources, or both. U.S. institutions lose ground in recruiting trainees who are attracted by opportunities for crosscultural interactions and career development.5–8 Underserved regions of the United States lose access to new physicians whose decisions to choose generalist- or public service-oriented careers or to practice in underserved communities could have been favorably influenced by global health-related experiences during their training.5,9,10 Finally, international partner institutions lose opportunities to provide learning experiences—not only locally, but also at institutions in the United States that are widely perceived to be among the most prestigious centers of higher education worldwide—that engage the minds of their best and that potentially help to mitigate some of the adverse effects of “brain drain” to other countries.31 A renewed focus on innovative mechanisms to expand the scope and reach of obstetrics and gynecology global health residency programs is an important area for future educational and operational research.
Our analysis found a statistically significant cross-country association between the intensity of programmatic activity and the burden of maternal and perinatal conditions. However, we observed a negative but nonstatistically significant association for gynecologic cancers, a trend that appeared to be driven principally by negative associations between programmatic activity and the burden of uterine and ovarian cancers. These inconsistent findings are likely the result of several factors. First, in our experience, myriad factors influence program placement in low-resource settings, including the availability of funding, identification of partner institutions, or both, and these may bear little to no relation to the country-level burden of disease for any particular condition. Second, the greater infrastructure required to provide effective care for gynecologic malignancies compared with benign obstetrics and gynecology (such as the more involved surgeries and the need for radiotherapy, chemotherapy, and supportive care for medically complex patients—potentially addressable through emerging care delivery models32) may pose a barrier to involvement by U.S. trainees on a short-term, skill-limited basis. Third, we could not rule out unobserved confounding. For example, low-resource countries are known to have a lower burden of ovarian and uterine cancers.33 If programmatic activities are primarily being directed to low-resource countries (ie, irrespective of their burden of ovarian and uterine cancer), this could produce the associational patterns observed here. Overall, however, the data suggest a trend of U.S. obstetrics and gynecology residents obtaining their global health training experiences in countries with greater disease burdens. To ensure that such momentum continues, residency leadership bodies such as the Council on Resident Education in Obstetrics and Gynecology could convene strategic meetings to share best practices and logistical models, as has been proposed for the Association of Program Directors in Surgery.23 Priority-setting exercises, similar to those that have been conducted to guide investments in global health research,34–36 could also provide concrete guidance about the placement of new global health training activities. Finally, program evaluations similar to those that have been completed for other disciplines4,37 should be planned, perhaps using the Accreditation Council for Graduate Medical Education core competencies as an outline for identifying measurable outcomes.
Interpretation of our data is subject to several important limitations. First, the Internet-based search protocol may have had low sensitivity for identifying obstetrics and gynecology residency programs with global health training. For example, some residency training programs may offer global health training either formally or informally without describing such activity on their programs' web sites.23 Many faculty members in departments of obstetrics and gynecology are engaged in global health research or clinical care activities and invite residents to participate without establishing longitudinal curricula or formal programs. Alternatively, the information contained on the programs' web sites could simply be out of date. Although a nationwide survey of residency program directors could potentially have yielded a more in-depth and current characterization of global health-related programmatic activities, previous surveys of program directors21–23 and residents8 have been characterized by relatively low response rates and, therefore, unpredictable biases. Second, our review excluded several institution-wide global health programs that do not provide opportunities for obstetrics and gynecology residents. These include, for example, the Yale/Stanford Johnson and Johnson Global Health Scholars Program and the Mount Sinai Global Health Residency Track, which enroll residents from several different specialties but do not enroll obstetrics and gynecology residents. Third, our review did not account for institutions offering fellowship-level training in global health38 as well as residency programs offered by institutions in other high-income countries. As a result, our review therefore explicitly excluded programs such as the Duke Global Health Residency/Fellowship Pathway and the Academic Model Providing Access to Healthcare Reproductive Health program led by the University of Toronto.
This study represents a unique assessment of the scope of global health-related programmatic activities available to U.S. obstetrics and gynecology residents. We found that there are relatively few global health training opportunities but that these appear to be distributed according to the global burden of maternal and perinatal conditions. Given the limitations we described as well as the fact that global health-related programmatic activity in U.S. obstetric and gynecologic education is rapidly evolving, the field has an opportunity to further deepen its involvement and leadership in this area. Carefully planned program evaluations and priority setting exercises will help to ensure that global health programs in U.S. graduate obstetrics and gynecology education achieve their goals of increasing women's access to health care and reducing the burden of disease resulting from maternal and perinatal conditions worldwide.
1. Hill DR, Ainsworth RM, Partap U. Teaching global public health in the undergraduate liberal arts: a survey of 50 colleges. Am J Trop Med Hyg 2012;87:11–5.
2. Heck JE, Wedemeyer D. International health education in US medical schools: trends in curriculum focus, student interest, and funding sources. Fam Med 1995;27:636–40.
3. Kerry VB, Ndung’u T, Walensky RP, Lee PT, Kayanja VF, Bangsberg DR. Managing the demand for global health education. PLoS Med 2011;8:e1001118.
4. Tsai AC, Ordóñez AE, Reus VI, Mathews CA. Eleven-year outcomes from an integrated residency program to train research psychiatrists. Acad Med 2013;88:983–8.
5. Gupta AR, Wells CK, Horwitz RI, Bia FJ, Barry M. The international health program: the fifteen-year experience with Yale University's internal medicine residency program. Am J Trop Med Hyg 1999;61:1019–23.
6. Dey CC, Grabowski JG, Gebreyes K, Hsu E, VanRooyen MJ. Influence of international emergency medicine opportunities on residency program selection. Acad Emerg Med 2002;9:679–83.
7. Bazemore AW, Henein M, Goldenhar LM, Szaflarski M, Lindsell CJ, Diller P. The effect of offering international health training opportunities on family medicine residency recruiting. Fam Med 2007;39:255–60.
8. Anspacher M, Frintner MP, Denno D, Pak-Gorstein S, Olness K, Spector J, et al.. Global health education for pediatric residents: a national survey. Pediatrics 2011;128:e959–65.
9. Thompson MJ, Huntington MK, Hunt DD, Pinsky LE, Brodie JJ. Educational effects of international health electives on U.S. and Canadian medical students and residents: a literature review. Acad Med 2003;78:342–7.
10. Jeffrey J, Dumont RA, Kim GY, Kuo T. Effects of international health electives on medical student learning and career choice: results of a systematic literature review. Fam Med 2011;43:21–8.
11. Drain PK, Holmes KK, Skeff KM, Hall TL, Gardner P. Global health training and international clinical rotations during residency: current status, needs, and opportunities. Acad Med 2009;84:320–5.
12. Lozano R, Naghavi M, Foreman K, Lim S, Shibuya K, Aboyans V, et al.. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012;380:2095–128.
13. Ivers LC, Garfein ES, Augustin J, Raymonville M, Yang AT, Sugarbaker DS, et al.. Increasing access to surgical services for the poor in rural Haiti: surgery as a public good for public health. World J Surg 2008;32:537–42.
14. Taira BR, Kelly McQueen KA, Burkle FM Jr. Burden of surgical disease: does the literature reflect the scope of the international crisis? World J Surg 2009;33:893–8.
15. Debas HT, Gosselin R, McCord C, Thind A. Surgery. In: Jamison DT, Breman JG, Measham AR, Alleyne G, Claeson M, Evans DB, et al., editors. Disease control priorities in developing countries, 2nd ed. New York (NY) and Washington (DC): Oxford University Press and The International Bank for Reconstruction and Development; 2006. p. 1245–60.
16. Kingham TP, Kamara TB, Cherian MN, Gosselin RA, Simkins M, Meissner C, et al.. Quantifying surgical capacity in Sierra Leone: a guide for improving surgical care. Arch Surg 2009;144:122–7.
17. Choo S, Perry H, Hesse AA, Abantanga F, Sory E, Osen H, et al.. Assessment of capacity for surgery, obstetrics and anaesthesia in 17 Ghanaian hospitals using a WHO assessment tool. Trop Med Int Health 2010;15:1109–15.
18. Linden AF, Sekidde FS, Galukande M, Knowlton LM, Chackungal S, McQueen KA. Challenges of surgery in developing countries: a survey of surgical and anesthesia capacity in Uganda's public hospitals. World J Surg 2012;36:1056–65.
19. Grimes CE, Law RS, Borgstein ES, Mkandawire NC, Lavy CB. Systematic review of met and unmet need of surgical disease in rural sub-Saharan Africa. World J Surg 2012;36:8–23.
20. Shirazian T, Ascher-Walsh C, Brodman M. Global women's healthcare in obstetrics and gynecology: a model for resident programs. Contemp Ob Gyn 2012;57:48–51.
21. Nelson BD, Lee AC, Newby PK, Chamberlin MR, Huang CC. Global health training in pediatric residency programs. Pediatrics 2008;122:28–33.
22. Jayaraman SP, Ayzengart AL, Goetz LH, Ozgediz D, Farmer DL. Global health in general surgery residency: a national survey. J Am Coll Surg 2009;208:426–33.
23. Mitchell KB, Tarpley MJ, Tarpley JL, Casey KM. Elective global surgery rotations for residents: a call for cooperation and consortium. World J Surg 2011;35:2617–24.
24. Mathers C, Boerma JT, Fat DM. The global burden of disease: 2004 update. Geneva (Switzerland): World Health Organization; 2008.
25. Kolars JC, Halvorsen AJ, McDonald FS. Internal medicine residency directors perspectives on global health experiences. Am J Med 2011;124:881–5.
26. Klaristenfeld DD, Chupp M, Cioffi WG, White RE. An international volunteer program for general surgery residents at Brown Medical School: the Tenwek Hospital Africa experience. J Am Coll Surg 2008;207:125–8.
27. Ozgediz D, Roayaie K, Debas H, Schecter W, Farmer D. Surgery in developing countries: essential training in residency. Arch Surg 2005;140:795–800.
28. Powell AC, Casey K, Liewehr DJ, Hayanga A, James TA, Cherr GS. Results of a national survey of surgical resident interest in international experience, electives, and volunteerism. J Am Coll Surg 2009;208:304–12.
29. Ozgediz D, Wang J, Jayaraman S, Ayzengart A, Jamshidi R, Lipnick M, et al.. Surgical training and global health: initial results of a 5-year partnership with a surgical training program in a low-income country. Arch Surg 2008;143:860–5.
30. Schecter WP, Farmer D. Surgery and global health: a mandate for training, research, and service—a faculty perspective from the UCSF. Bull Am Coll Surg 2006;91:36–8.
31. Klufio CA, Kwawukume EY, Danso KA, Sciarra JJ, Johnson T. Ghana postgraduate obstetrics/gynecology collaborative residency training program: success story and model for Africa. Am J Obstet Gynecol 2003;189:692–6.
32. Farmer P, Frenk J, Knaul FM, Shulman LN, Alleyne G, Armstrong L, et al.. Expansion of cancer care and control in countries of low and middle income: a call to action. Lancet 2010;376:1186–93.
33. Soerjomataram I, Lortet-Tieulent J, Parkin DM, Ferlay J, Mathers C, Forman D, et al.. Global burden of cancer in 2008: a systematic analysis of disability-adjusted life-years in 12 world regions. Lancet 2012;380:1840–50.
34. Rudan I, Gibson JL, Ameratunga S, El Arifeen S, Bhutta ZA, Black M, et al.. Setting priorities in global child health research investments: guidelines for implementation of CHNRI method. Croat Med J 2008;49:720–33.
35. Rudan I, Chopra M, Kapiriri L, Gibson J, Ann Lansang M, Carneiro I, et al.. Setting priorities in global child health research investments: universal challenges and conceptual framework. Croat Med J 2008;49:307–17.
36. Tomlinson M, Rudan I, Saxena S, Swartz L, Tsai AC, Patel V. Setting priorities for global mental health research. Bull World Health Organ 2009;87:438–46.
37. Gourevitch MN, Jay MR, Goldfrank LR, Mendelsohn AL, Dreyer BP, Foltin GL, et al.. Training physician investigators in medicine and public health research. Am J Public Health 2012;102:e39–45.
38. Goodman A, Clark RM, Bradford LS. Caring for women with gynecologic cancers around the world: the need for global health training in gynecologic oncology fellowship programs. Am J Clin Oncol 2012;35:511–3.